1. Quality improvement approaches to improve nutritional care
Caroline Lecko
Clinical Improvement Manager
Nursing Directorate
NHS Improvement
@celecko

2. Summary of the Nutrition and Hydration Board Assurance Survey
Overview of the Nutrition Improvement Collaborative

3. Nutrition and Hydration Board Assurance Survey – October 2017
Results summary
Title slide with embedded images

4. Q1: Please identify which type of trust you are from:
Answered Skipped 0

5. Q3: Do you have a non-executive director champion for nutrition and hydration?
Answered: Skipped: 1

6. Q4: Does your organisation have a hospital food strategy that is publically available?
Answered: Skipped: 2

7. Q5: How often do you discuss the nutritional care of patients at your trust board meetings?
Answered: Skipped: 1

8. Q6: Do you have nutrition and hydration quality measures that are reported to your trust board?
Answered: Skipped: 1

9. 10: Please indicate how NHS Improvement could support you to provide board assurance in the future:
There was a total of 37 responses which could be summarised into the following themes:
Measures, metrics, guidelines
Sharing examples of good practice, networking
Strategy development (nutrition and hydration)
Developing effective nutritonal steering groups
Cross system working (guidance and policies)
Establishment Nutrition collaborative

10. NHS Improvement Nutrition Collaborative
The NHS Improvement Nursing Directorate Nutrition Collaborative (cohort 1) was an improvement collaborative which run over a 180-day improvement cycle commencing in November 2017 and concluding in May 2018.
The overall aims of the collaborative were to support organisations:
Increase in the proportion of patients with an accurate nutritional screen
Increase in the proportion of patients receiving appropriate nutritional interventions
Introduce and increase the use quality improvement tools and techniques

11. Collaborative participants
Oral health
Twenty-five NHS provider organisations were recruited to be part of the collaborative from a range of acute and community providers
General health
London Region 1
South Region
Midlands and East Region 18
North Region 6

12. NHS Improvement collaborative teams
Central Nursing Directorate
Professor Mark Radford – Director of Nursing (Improvement)
Jane Robinson – Clinical Improvement Project Lead
Caroline Lecko – Clinical Improvement Manager
Caroline Poole – Professional Head of Allied Health Professions (AHPs)
Ruth Olaitan - Project Manager-Nursing
Shirley Littlewood - PA to Prof Mark Radford
Regional Support
Organisational Teams
Each of the organisations were asked to identify:
Executive sponsor
Project lead
Multi-professional (nursing, dietetic, speech and language therapist, catering/facilities)

13. Collaborative approach
180-day improvement cycle four collaborative events were held bi- monthly
Each participating organisation was expected to send their collaborative team or representatives to each of these events.
Each of the four events included presentations from external speakers to share good practice, opportunity for organisations to share their improvement journey to date and an introduction to a quality improvement method or tool.
November
Launch event
January
Measurement for Improvement
March
Spread and Sustainability
May
Celebration

14. The Quality Improvement journey…
Organisations readiness questionnaire
The questionnaire was adapted, with permission, from the US Malnutrition Quality Improvement Initiative (MQii) toolkit ( your-initiative.pdf)
Are you ready to improve nutritional care in your organisation?
Do you have the resources needed to do this?
Is your culture one of improvement?
20 questions considering:
Ability to support Quality Improvement efforts
Ability to support nutrition-focused Quality Improvement

15. Results
In total we received scores from seventeen of the collaborative organisations with scores ranging from 45 to 82
These scores reflected that the organisations were at varies stages of readiness from a stage of ‘lower readiness’ to ‘very good readiness’ at the start of the collaborative.
The collaborative teams were encouraged to look at the recommended actions, supplied as part of the questionnaire, for each stage of readiness and to build actions into your improvement plans to support their project.

16. Using the Model for Improvement
Aim
Measures
Ideas
Model for Improvement - Associates in Process Improvement

17. Key steps for identifying your quality improvement focus
1. Create a process map of existing care practices 2. Compare your care team’s current clinical processes to recommended care practices to identify where improvement efforts would be most beneficial 3. Identify a clinical improvement activity to enhance your organisations nutrition care process 4. Identify potential interventions for ideas of potential clinical improvements to implement with your care teams

19. An example:
The aim of this collaborative is:
- By August 2018, there will be a 25% improvement in the provision of appropriate MUST nutritional care plans by community nurses
The team outcome measure is:
- Number of nutritional screens performed that resulted in the provision of the appropriate care plan
The process measure was:
- Number of nutritional screens performed that have resulted in an accurate malnutrition score calculated using MUST

20. Measuring improvement
Collecting the baseline data
All teams were asked to collect base line data on simple run charts at the start of the collaborative

21. Measuring improvement
Statistical Process Control Chart (SPC)
For more detailed data collections a SPC chart was shared

22. Within the duration of the collaborative this
team undertook eleven data collections
and demonstrated an improvement
from 68% to 100% of MUST scores being
calculated correctly.

23. Other improvement tools
PLAN
We plan to: Publish a “Practice Development Team (PDT) Mythbuster” regarding accuracy of weights and not using estimated weights when completing MUST score. This will be published as part of Nutrition Week on 12th March 2018.
We hope this produces: We hope to increase the knowledge of the significance of using an accurate weight for MUST scoring; not using estimated weights and if weighing a patient is not possible, to use the mid upper arm circumference (MUAC) measurement
Steps to execute:
Develop mythbuster and ensure key stakeholders have reviewed.
Publish on PDT internet page and disseminate to senior sisters/ charge nurses/ band 6 nurses, CNS’s and matrons on Monday 12th March for the start of Nutrition Week DO
What did you observe?
Dietetic mini audit (March 2018) looking at 9 wards/dept and comparing before and after the MUST training, showed an increase in the accuracy of the dietetic referrals and reduced use of estimated weights as part of the MUST score. This suggests that MUST scores are more accurate following education.
STUDY
What did you learn? Did you meet your measurement goal?
Positive feedback from staff relating to “Mythbuster” format.
Poor use of MUAC in March 2018 audit but myth only published during Nutrition week, therefore difficult to conclude impact.
ACT
What did you conclude from this cycle?
Success of “Mythbuster” format for communicating single messages about practice.
Driver Diagrams
Plan, Do, Study, Act (PDSA cycles)

24. All presented as…

25. Evidence of improvement
Seventeen of the twenty-five (72%) collaborative teams submitted information at the end of the collaborative in the form of storyboards.
Of the seventeen, eleven (64%) were able to demonstrate improvement in the accuracy of nutritional screening in one of more of their collaborative pilot areas. One team, reported a decrease in the accuracy of nutritional screening but were able to demonstrate improvement in the timeliness of screening.
Three of teams focused specifically on the appropriateness of nutritional interventions, two (66%) of which demonstrated improvement and remaining team’s data remained unchanged during the collaborative.
One team did not focus on the any of the overall aims of the collaborative, instead concentrating on gaining board assurance.
This would suggest that overall improvement against one or more of the overall aims of collaborative was approximately 65%.

26. Next steps
Second cohort of the collaborative running from September 2018 to March 2019
Five of the organisations involved in cohort 1 of the collaborative have offered to support cohort 2 by sharing their improvement journey experiences
Work is currently underway with colleagues at the Malnutrition Quality Improvement Initiative (MQii) in the United States of America (USA) to link the planned USA and NHS Improvement collaboratives. This joint working will have the benefit of being able to share the specific malnutrition quality improvement resources developed by MQii, along with promoting cross nation learning and comparisons of the impact of quality improvement approaches to reducing malnutrition.
Regional learning collaborative – 1st meeting 14 November - North

27. Thank you caroline.lecko@nhs.net @celecko